Healthcare Provider Details

I. General information

NPI: 1548367964
Provider Name (Legal Business Name): SPECTRUM HEALTH KENT COMMUNITY CAMPUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

750 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-4200
  • Fax: 616-486-2419
Mailing address:
  • Phone: 616-391-4200
  • Fax: 616-643-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: KEVIN SMITH
Title or Position: VP FINANCE
Credential:
Phone: 616-486-2672